CPC exam- Practice Questions
1. Financial information: Which of the following elements is not a component of
most patient records?
Patient Idenfification
Clincal History
Financial Information
Test Results
2. Operative report: Identify where the following information would be found in the
acute care record. Following induction of an adequate general anesthesia, and with
the patient supine on the padded table, the left upper extremity was prepped and
draped in the standard fashion.
Anesthesia report
Physican progress report
Operative report
Recovery Room Record
3. Medical Laboratory Report: Identify where the following information would be
found in the acute care record. "cbc: wbc 12.0, rbc 4.65, HGB 14.8, HCT 43.8"
Medical Laboratory report
Pathology report
physical examination
physician orders
4. Radiology Report: Identify where the following information would be found in
the acute-care record" "PA and Lateral Chest, The lungs are clear. The heart
and mediastinum are normal size and configuration. There are minor degenerative
changes of the lower thoracic spine
Medical laboratory report
Physical examination
Physician progress note
Radiography report
5. Physical examination: The following is documented in an acute care record:
"HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No
obvious head trauma. Chest: Good Bilateral chest sounds." Where would this infor-
mation be documented
History
Pathology report
, CPC exam- Practice Questions
Physical examination
Operation Report
6. Pathology report: The following is documented in an acute care record: "Mi-
croscopic: Sections are of squamous mucosa with no atypic." Where would this
information be documented?
History
Pathology report
Physical examination
Operation Report
7. Admission order: The following is documented in an acute care record: Admit
to 3c, Diet NPO, Meds: Compazine 10 mg, Where would this information be docu-
mented.
Admission order
History
Physical examination
Progress notes
8. Newborn record: The following is documented in an acute care record: 38
weeks gestation, Apgars 8/9, 6# 8oz, good cry" Where would this information be
documented.
Admission note
Clinical laboratory
Newborn record
physician order
9. ECG Report: The following is documented in an acute care record: Atrial Fibrilla-
tion with rapid ventricular repose, left axis deviation, left bundle branch block." Where
would this information be documented.
Admission Order
Clinical Laboratory Report
ECG Report
radiology report
10. Consultation Report: The following is documented in an acute care record:
I was asked to evaluate this level 1 trauma patient with an open left humeral
epicondylar fracture. Recommendations: Proceed with urgent surgery for debride-
ment, irrigation, and treatment of open fracture." Where would this information be
documented.
, CPC exam- Practice Questions
Admission Note
Consultation Report
discharge summary
Nursing Progress Notes
11. Social Work Note: The following is documented in an acute care record: Spoke
to the attending re: my assessment. Provided adoption and counseling information.
Spoke to CPS re: referral. Case manager to meet with patient and family." Where
would this information be documented.
Admission note
Nursing Note
Physican process note
Social Work Note
12. UHDDS: Mary Smith, RHIA, has been charged with the responsibility of design-
ing a data collection form to be used on admission of a patient to the acute care
hospital in which she works. The first resource that she should use is .
UHDDS
UACDS
MDS
ORYX
13. performance improvement programs: Both HEDIS and the Joint Commis-
sion's ORYX program are designed to collect data to be used for:
performance improvement programs
billing and claims data processing
developing hospital discharge abstracting systems
developing individual care plans for residents
14. Subjective: A notation for a diabetic patient in a physician progress note reads:
"Occasionally gets hungry. No insulin reactions. She says she is following her
diabetic diet." In which part of a problem-oriented medical record progress note
would this be written?
Subjective
Objective
Assessment
Plan
, CPC exam- Practice Questions
15. Objective: A notation for a diabetic patient in a physician progress note reads:
FBS 110mg%, using sugar, no acetone. In which part of a problem-oriented medical
record progress note would this be written?
Subjective
Objective
Assessment
Plan
16. Plan: A notation for a hypertensive patient in a physician ambulatory care
progress note reads: "Continue with diurnal, 500 msg once daily. return in 2 weeks"
In which part of a problem-oriented medical record progress note would this be
written?
Subjective
Objective
Assessment
Plan
17. Assessment: A notation for a hypertensive patient in a physician ambulatory
care progress note reads: "Blood pressure adequately controlled" In which part of a
problem-oriented medical record progress note would this be written?
Subjective
Objective
Assessment
Plan
18. Quantitative: Reviewing a health record for missing signatures, missing medical
reports, and ensuring that all documents belong in the health record is an example
of review.
Quantitative
Qualitative
Statistical
Outcome
19. Data currency: Dr. Jones entered a progress note in a patient's health record 24
hours after he visited the patient. Which quality element is missing from the progress
note?
Data Completeness
Data relevancy
1. Financial information: Which of the following elements is not a component of
most patient records?
Patient Idenfification
Clincal History
Financial Information
Test Results
2. Operative report: Identify where the following information would be found in the
acute care record. Following induction of an adequate general anesthesia, and with
the patient supine on the padded table, the left upper extremity was prepped and
draped in the standard fashion.
Anesthesia report
Physican progress report
Operative report
Recovery Room Record
3. Medical Laboratory Report: Identify where the following information would be
found in the acute care record. "cbc: wbc 12.0, rbc 4.65, HGB 14.8, HCT 43.8"
Medical Laboratory report
Pathology report
physical examination
physician orders
4. Radiology Report: Identify where the following information would be found in
the acute-care record" "PA and Lateral Chest, The lungs are clear. The heart
and mediastinum are normal size and configuration. There are minor degenerative
changes of the lower thoracic spine
Medical laboratory report
Physical examination
Physician progress note
Radiography report
5. Physical examination: The following is documented in an acute care record:
"HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No
obvious head trauma. Chest: Good Bilateral chest sounds." Where would this infor-
mation be documented
History
Pathology report
, CPC exam- Practice Questions
Physical examination
Operation Report
6. Pathology report: The following is documented in an acute care record: "Mi-
croscopic: Sections are of squamous mucosa with no atypic." Where would this
information be documented?
History
Pathology report
Physical examination
Operation Report
7. Admission order: The following is documented in an acute care record: Admit
to 3c, Diet NPO, Meds: Compazine 10 mg, Where would this information be docu-
mented.
Admission order
History
Physical examination
Progress notes
8. Newborn record: The following is documented in an acute care record: 38
weeks gestation, Apgars 8/9, 6# 8oz, good cry" Where would this information be
documented.
Admission note
Clinical laboratory
Newborn record
physician order
9. ECG Report: The following is documented in an acute care record: Atrial Fibrilla-
tion with rapid ventricular repose, left axis deviation, left bundle branch block." Where
would this information be documented.
Admission Order
Clinical Laboratory Report
ECG Report
radiology report
10. Consultation Report: The following is documented in an acute care record:
I was asked to evaluate this level 1 trauma patient with an open left humeral
epicondylar fracture. Recommendations: Proceed with urgent surgery for debride-
ment, irrigation, and treatment of open fracture." Where would this information be
documented.
, CPC exam- Practice Questions
Admission Note
Consultation Report
discharge summary
Nursing Progress Notes
11. Social Work Note: The following is documented in an acute care record: Spoke
to the attending re: my assessment. Provided adoption and counseling information.
Spoke to CPS re: referral. Case manager to meet with patient and family." Where
would this information be documented.
Admission note
Nursing Note
Physican process note
Social Work Note
12. UHDDS: Mary Smith, RHIA, has been charged with the responsibility of design-
ing a data collection form to be used on admission of a patient to the acute care
hospital in which she works. The first resource that she should use is .
UHDDS
UACDS
MDS
ORYX
13. performance improvement programs: Both HEDIS and the Joint Commis-
sion's ORYX program are designed to collect data to be used for:
performance improvement programs
billing and claims data processing
developing hospital discharge abstracting systems
developing individual care plans for residents
14. Subjective: A notation for a diabetic patient in a physician progress note reads:
"Occasionally gets hungry. No insulin reactions. She says she is following her
diabetic diet." In which part of a problem-oriented medical record progress note
would this be written?
Subjective
Objective
Assessment
Plan
, CPC exam- Practice Questions
15. Objective: A notation for a diabetic patient in a physician progress note reads:
FBS 110mg%, using sugar, no acetone. In which part of a problem-oriented medical
record progress note would this be written?
Subjective
Objective
Assessment
Plan
16. Plan: A notation for a hypertensive patient in a physician ambulatory care
progress note reads: "Continue with diurnal, 500 msg once daily. return in 2 weeks"
In which part of a problem-oriented medical record progress note would this be
written?
Subjective
Objective
Assessment
Plan
17. Assessment: A notation for a hypertensive patient in a physician ambulatory
care progress note reads: "Blood pressure adequately controlled" In which part of a
problem-oriented medical record progress note would this be written?
Subjective
Objective
Assessment
Plan
18. Quantitative: Reviewing a health record for missing signatures, missing medical
reports, and ensuring that all documents belong in the health record is an example
of review.
Quantitative
Qualitative
Statistical
Outcome
19. Data currency: Dr. Jones entered a progress note in a patient's health record 24
hours after he visited the patient. Which quality element is missing from the progress
note?
Data Completeness
Data relevancy
